Prescribed Fire Lessons Learned
Escape Prescribed Fire Reviews
and
Near Miss Incidents Initial Impression Report June 29, 2005 Prepared by Deirdre M. Dether Submitted to Wildland Fire Lessons Learned Center
Summary of Escaped Prescribed Fire
Reviews and Near Miss Incidents What key lessons have been learned and what knowledge gaps exist? Introduction This analysis is the first known attempt to take a comprehensive look at escaped prescribed fire reviews and near misses. A total of 30 prescribed fire escape reviews and ‘near misses’ (see Appendix A and B) were analyzed to discover what, if any reoccurring lessons were being learned, or whether they were indicating emerging knowledge gaps or trends. It is estimated that Federal land management agencies complete between 4,000 and 5,000 prescribed fires annually. Approximately ninety­nine percent of those burns were ‘successful’ (in that they did not report escapes or near misses). This can be viewed as an excellent record, especially given the elements of risk and uncertainty associated with prescribed fire. However, that leaves 40 to 50 events annually we should learn from. This report is intended to assist in that effort. Evaluating formal reviews and After Action Reviews (AAR) can be a tool for burn personnel to expand their knowledge and supplement their own direct experiences. When reviews go beyond policy and accountability questions they can provide information that can add to our own direct experiences by broadening exposure to what can occur. Learning from other experiences may help avoid undesired outcomes. The intent of this report is not to point out ‘wrong decisions’, but rather it is to use all these individual ‘events’ to see if there are common themes and/or ‘weak signals’ occurring with these escapes and near miss events. The main focus of the analysis was to look for things prescribed fire practitioners could use as they prepare for future prescribed fires. Are there some factors that prescribed fire planners and/or burn bosses have been repeating in isolation? If so, what should be shared with others involved in the planning and execution of prescribed burns to continue to improve outcomes? Methods Three questions drove this inquiry: Can comparing these reviews allow us to glean important or emerging trends? Can these reviews help all agencies to learn? and Are we asking the right questions? Next, I posed three straight­forward questions: of the analysis addresses straightforward questions. Are there common reported ‘causes’ contributing to the escapes/near misses? Are there repeated findings and ‘lessons learned’ cited in the reviews? What are these? Lastly, I looked for potential emerging trends or patterns gleaned from collectively evaluating all the reviews. The trends or patterns may indicate a ‘blind spot’ that was not previously apparent without looking at all the reports together as opposed to an individual basis.
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The Dataset Formal and information documentation from four federal land management agencies (FS, BLM, NPS and FWS) was evaluated in this assessment. Unlike the BLM, the FS did not appear to have a consistent formal review and documentation process. Both the FWS and NPS had too few samples collected to determine their questions and processes, even though current policies for these agencies provide a standardized process I reviewed 30 reports written for escapes or near­misses that occurred between 1996 and 2004. Only documents submitted to the Wildland Fire Lessons Learned Center (LLC), collected from agency websites by agency personnel, or located in personal ‘collections’ were used in this assessment (see Figure 1). It is unknown where and how many other reports may be available. This is an indicator that knowledge is not commonly retained and shared from these experiences so agencies have a greater likelihood of repeating ‘mistakes.’ Of these 30, most were formal escape prescribed fire reviews, several were draft review documents one was in a power point presentation, and two were After Action Reviews (AAR) of ‘near miss’ incidents. Most often the review was conducted at the request of an agency administrator following agency policy. The two ‘near misses’ were not declared escape prescribed fires, but the After Action Reviews provided valuable insights so were included in this analysis. Figure 1 Number of reviews by year used in this analysis from 1996 to 2004 Number of Reviews and Near Miss Incidents N = 30 8 7 6 5 4 3 2 1 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 Escapes NOTE: It should not be construed that the years are problematic years since not all agencies systematically report escapes or near misses.
Near Miss Geographic area covered includes: several regions of the Forest Service including Northern Rockies (R1), Rocky Mountain (R2), Southwest (R3), Intermountain (R4), Pacific Southwest (R5), Southern (R8) and Alaska (R10). Reviews from Department of Interior agencies including BLM District and Field Offices; National Park Service units; and Fish and Wildlife Service were also used (see Figure 2). The states in alphabetical order (and number of reviews from each state) include Alaska (1), Arizona (5), California (3), Colorado (1), Florida (1), Idaho (2), Kansas (1), Montana (1), Nevada (1), New Mexico (3), Oregon (1), South Dakota (1), Utah (6) and Wyoming (3). Several vegetation­fuel complexes discussed in the reviews including: ponderosa pine, mixed conifer, and sub­ alpine fir, pinyon/juniper, chaparral, sagebrush/aspen, oak brush, grass, and activity fuels (slash). 1
The escapes or near miss incidents span from February to October. Most of the escapes were ignited in May (7) and June (5). Both near miss incidents occurred in September. Due to the many geographic areas represented in the sample it was not possible to evaluate any trends related to season. The amount of acres planned for ignition ranged from less than 5 acres up to several thousand acres for individual burn blocks. Several of the more recent escapes involved ignitions on multiple large­scale burn blocks. NOTE: It should not be construed any one agency has more or less escapes than another since escapes and near misses are systematically reported.
# Escapes/Near Misses Figure 2 Number of reports by agency used in this analysis. Incidents Reviewed by Agency 14 12 10 8 6 4 2 0 BLM FWS Escape NPS FS Near Miss NOTE: this analysis evaluated 30 total events, 28 of which were escapes over a nine­year period or an average of 3 per year (less than 8% of the estimated 40 to 50 escapes occurring annually on average). Of the 99% ‘successful’ burns we, as an ‘organization’ have no idea about the ‘near misses’ and ‘successful saves’ that have occurred. Many other escapes and near misses have occurred, but it is unknown how much formal or informal documentation exists from which we could gain experience. Of the thirty reports evaluated, several mentioned other escapes and near miss events, but only one report (one of the near misses) could be connected to another escape prescribed fire reviewed during this analysis. However, several escaped prescribed fire reviews involved multiple landscape­sized projects ignited either simultaneously or days apart, so they were covered in one review document. Background The concepts of a High Reliability Organization fit with the planning and execution of prescribed fire A High Reliability Organization (HRO) is one that experiences less than it’s fair share of incidents. Being and acting like a HRO should apply to organizations using prescribed fire to accomplish land management objectives. The use of fire is a high­risk business that operates in a highly variable environment yet needs to produce reliable outcomes. The excerpts provided below from Managing the Unexpected (Weick and Sutcliffe 2001) are here to set the context. This analysis is an initial attempt at applying the practices and principles and practices of how a HRO would evaluate escaped prescribed fires and near miss incidents. 2 All High Reliability Organizations Heed Close Calls and Near Misses
(from Keller October 2004)
High Reliability Organizations:
Regard close calls and near misses as a kind of failure that reveals potential
danger, rather than as evidence of the organization’s success and ability to
avoid danger. They pick up on these potential clues early on—before they
become bigger and more consequential.
Know that small things that go wrong are often early warning signals of
deepening trouble that provide insight into the health of the whole system.
Treat near misses and errors as information about the health of their
systems and try to learn from them.
Are preoccupied with all failures, especially the small ones.
Understand that if you catch problems before they grow bigger, you have
more possible ways to deal with them.
There are five practices of a HRO that can be grouped into two functional
categories (Weick and Sutcliffe 2001).
Mindful ‘Anticipation’ of the
Unexpected Mindful ‘Containment’ of the
Unexpected Preoccupation with Failure Reluctance to Simplify Sensitivity to Operations Commitment to Resilience Deference to Expertise Results
What questions are being asked in an escape review ? Since reports were often generated to meet agency direction the questions mostly focused on policy and accountability issues. The most common questions were: A. Is agency policy, guidance and/or direction adequate? Was is followed? Initial observation – Most of the reviews determined that good or sound policy and guidance existed. However, when review teams looked at whether policy was followed, the answer was not always a yes. In a few cases, review teams also compared the local level direction relative to national direction. In at least four cases the finding was the same. The local direction was not consistent or was outdated relative to existing national direction at the time of the escape.
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B. Was the burn plan prepared and executed relative to agency policy? Was it a ‘good’ plan? Initial observation – Few reviews concluded that burn plans did not meet policy. However most listed several weaknesses or noted parts missing in burn plans. Common areas cited as weak within the burn plans included complexity and risk assessments, and thoroughness of the ignition, holding and contingency plans. Another reoccurring issue was the lack of fire behavior calculations. Sometimes the fuel model did not accurately represent the fuels and potential fire behavior of the burn area. The fuel model selected generally under­predicted potential fire behavior. Another reoccurring problem was that all the fuel types within the burn area were not evaluated and incorporated into the burn plan. Some of the reviews also noted that burn personnel failed at times to follow what was in the burn plan. This includes obtaining spot weather forecasts or monitoring weather and other prescription parameters for the timeframes specified prior to ignition. Not all procedures were followed during execution. Reviews noted that required documentation was often poor or lacking. C. Was the planning and execution of the prescribed burn done by qualified personnel? Initial observation –In only two of the reviews were questions concerning the qualifications of burn personnel an issue. In one case the burn boss was from another agency so the reviewing agency was uncertain if the individual was qualified and needed to verify qualification documentation with the other agency. In the other case, the question was whether proper certification procedures were followed. However, several of the reviews noted that burn bosses, while ‘qualified’, were often ‘inexperienced’ with the fuel type(s), which contributed to the escape of the prescribed burn. In addition, I noticed a trend towards including questions beyond policy, accountability and qualifications. Such reviews are moving toward ‘lessons learned’ and what needs to be improved and applied to future projects. Two reports included in this analysis did not involve an escaped prescribed fire, but shared near misses which indicates a movement beyond focusing on accountability. Other Observations Other questions raised were developed based on issues that were specific to that particular event. However, it was interesting to note there were some common themes among those areas evaluated by review teams. At least 10 of the 28 escaped fires burned onto private ground. Therefore, one area added on often looked at how well collaboration, communication and coordination occurred with the public and between cooperating agencies. Not all reviews evaluated the linkage of the environmental document to the burn plan. Often when this was done there were missing mitigations from the NEPA document that were not incorporated into the burn plan. All stopped at the point of looking at actions beyond the escape although most noted that there was safe and successful transition from the prescribed fire to suppression actions.
6 Agencies are not yet fully behaving as a learning organization ­­ escapes
and near misses are not systematically and routinely reported, evaluated,
and shared.
What are the Common ‘Surprises’?
The ‘surprises’ came in three areas – Fuels and Fire Behavior, Weather and
Communication and Coordination. Many prescribed fire practitioners have already experienced one or more of these types of ‘surprises’ possibly all on the same prescribed burn whether the burn escaped or not. Several of the prescribed fire reviews and near misses expressed ‘surprise’ about the fire behavior they saw from the various vegetation­ fuel complexes. In some cases, the personnel involved with the burn knew to expect something different than what models predicted, but the fire behavior (either rate of spread and/or flame lengths) was not even imaginable. A re­occurring theme mentioned by the reviews was that many escapes occurred because conditions were not ‘normal’ (e.g. periods of drought, warmer and drier than normal). When burns were implemented, burn personnel ‘failed to adjust operational procedures’ to account for the ‘abnormal’ conditions. Since surprises, expectations and the ability to manage the unexpected are linked together; therefore it is important to focus on what surprised burn personnel, and why. In Managing the Unexpected Weick and Sutcliffe (2001) state that ‘surprises’ come in many different varieties. Prescribed burn personnel have experienced many of the ‘varieties of surprise’ listed below. Weick and Sutcliffe describe what can occur if we blindly follow expectations and do not update them with new information. “The continuing search for confirming evidence postpones the realization that something unexpected is developing. If you are slow to realize that things are not the way you expected them to be, the problem worsens and becomes harder to solve. When it finally becomes clear that your expectation is wrong, there may be few options left to resolve the problem.”
Varieties of Surprise
1st Form – Something appears which you had no expectation, no prior model
of the event, no hint that it was coming.
2nd Form – The issue is recognized, but the direction of the expectation is
wrong.
3rd Form – Occurs when you know what will happen, when it will happen, and
in what order, but you discover the timing is off.
4th Form – Occurs when the expected duration of the event proves to be
wrong.
5th Form – Occur when the problem is expected, but the amplitude is not.
see Chapter 2 pages 35­39
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Surprises in Fuels and Fire Behavior ­ In numerous reviews, the rate of spread, flame length and resulting spotting caused much of the challenge for burn personnel. Fuels are often the source of unexpected or overlooked sources of trouble. One burn boss related this example of unexpected fire behavior in a fuel type involving standing dead pinyon­ juniper: the trees had been bug­killed with no needles left on the crown yet during burn operations the fire was able to move into the crowns of the standing dead trees and sustain fire spread through the aerial fuels much like a typical crown fire. In this case, an adequate control line stopped the spread of fire so the prescribed fire did not escape. Another example of unexpected fire behavior came from a small pocket of fuels adjacent to the burn area boundary. The small pocket of fuels was not the dominant fuel type within the burn area and was not noted in the burn plan as a potential source of heat and spotting. Another reoccurring ‘surprise’, reported in several escapes was greater than ‘normal’ fuel loading due to seasonal variation (greater moisture increased fine fuels) or a change in land management activities (area rested from grazing for 2 years prior to the burn actually being implemented). The change of conditions was not captured or discussed in the burn plan nor noted prior to ignition which would have caused a plan to be re­evaluated for complexity, risk and/or adequacy of contingency plans.
What are we not ‘seeing clearly’? Are we not appreciating how complex
burns are?
The use of natural barriers – change in fuel or vegetation type, moisture gradient either by changing topography or nighttime recovery often failed to check the spread of fire or put the fire out. In several cases changes in fuel or vegetation types were planned to check the spread of fire. In one case, aspen stands were to be used as a natural barrier to fire spread, but the aspen did not check spread as expected because the burn was not implemented during the planned season. In another case, a ‘swamp’ adjacent to the burn area was planned as a natural barrier. However, when the burn was implemented conditions had changed (i.e. the swamp was dry) and this area did not contain the spread. Prior to ignition burn personnel did not check whether this area would stop the spread of fire. With several prescribed burns, nighttime humidity recovery was expected to stop or check the spread of fire. In each case, burn personnel did not gather on­site information to confirm whether the area did experience sufficient humidity recovery. The review teams recommended that prescribed burns relying on this technique should staff the area through the night and monitor on­site conditions. Surprises in Weather – Surprises in weather often combined with or caused other surprises to occur. A number of reviews stated that ‘drought’ conditions were believed to be a contributing factor. In several cases changes in moisture (increased precipitation) changed the amount of fine fuels present at the time of the burn which was not accounted for in the burn plan. Unexpected winds (strength, duration, etc) were very common contributing factor to many escapes. Proximity of thunderstorms to burns may be another emerging knowledge gap or indicates a gap in ‘sense­making’. Burns that reported strong, erratic winds resulting from thunderstorm development nearby were ‘surprised’ by the effect. One case related that the storm was forecasted, they could see the cells developing miles away from the burn area, but felt that since the storm was approximately 30 miles away, they would be ‘ok”’ and proceeded with ignition. Another prescribed burn escaped due to the effects of a
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nearby thunderstorm. The weather forecast did predict the development of thunderstorm activity, but burn personnel did not recognize the potential impact to the prescribed burn. Surprises in Communication and Coordination – This was a common theme among the largest and most notable escapes (Lowden, Cerro Grande, Sanford, Cascade II and North Shore Kenai Lake). Other reviews noted concerns when burning adjacent to non­ agency lands. Two re­occurring themes were lack of proper notification and recommendations for developing agreements with adjacent landowners. Problems with lack of proper notification occurred prior to burning and/or timely notification once the prescribed burn had escaped burn boundaries. Proper notification of the individuals or agencies affected by an escape was often delayed because they did not know whom to contact. Developing relationships and contacts well before ignition followed by notification just prior to burning was a common recommendation. In cases where the prescribed burn escaped onto private ground an agreement with the landowner prior to the burn would have eliminated the need for declaring an escape. The lack of coordination and communication among key burn personnel and assisting/cooperating agencies or units also appeared to be a re­occurring theme in several escapes. What are the Common ‘Surprises’? Two patterns were observed and explored in this analysis. The first pattern was the tendency to underrate overall prescribed fire complexity using the NWCG complexity rating system. A second pattern emerged when chronologies of escaped prescribed burns were examined and evaluated for common causal factors. Although not all reports mentioned the overall complexity rating, most did indicate there were problems with how individual elements of the complexity rating system were addressed (e.g., underrated, missing rationale or reasons a particular rating was selected, or was inconsistent with the agency’s policy). This avenue was not explored further to determine if there were elements consistently underrated. Complexity ­ All agencies evaluated currently use the National Wildfire Coordinating Group (NWCG) complexity rating system (NWCG January 2004 NFES 2474). The complexity rating system consists of 14 elements to evaluate and determine risk, potential consequences and technical difficulty. The rating system is relatively comprehensive, and is designed to aid in selecting the correct level of difficulty. An initial rating is recommended during project planning and development followed by a final rating, which is done during burn plan development. The overall complexity rating was not systematically reported as part of the escaped prescribed fire review process. Half of the burns did not have the overall complexity rating reported although several within this group did note that elements of the complexity rating within the burn plan needed improvements (e.g. rationale for rating missing and if rated ‘high’ mitigations were not included in the burn plan per policy). There was a fairly even distribution between Low, Moderate and High complexity of those that did report the overall complexity rating of the burn (Figure 3). Review teams concluded that many burn plans with an overall rating of Low or Moderate were ‘underrated’ in complexity. That is, they were actually High complexity instead of Low or Moderate (see Figure 3). In several cases, one noted cause for underrating complexity was due to the preparer not following agency direction. A separate theme occurred when individual burns were rated Low to Moderate but then were implemented at the same time. Review teams noted burns conducted simultaneously would not warrant the same overall rating as the individual burn. In other words, two Low complexity burns implemented at the same time did not necessarily still rate a Low. Also noted in these cases was that burn personnel should have considered
9 changing the level of management oversight when conducting burns simultaneously (i.e. burn boss level switching from a RxB3 to and RxB2). However, the NWCG system specifically states that the “rating system is for a single prescribed fire project”. Figure 3 A comparison of overall complexity ratings for all projects reviewed. One column shows the complexity rating as determine during burn plan development versus the complexity rating determined during the review process. Overall Complexity Rating # of Escapes/Near Misses Escapes and Near Misses n=30 16 14 12 10 8 6 4 2 0 Low Moderate As Planned High Not Reported Determined After Chronologies – There were two distinct groups in terms of the length of time from test burn to escape declaration. Prescribed burns either escaped very quickly or escapes occurred several days after the main ignition period while in the patrol and monitoring phase. The chronologies of at least 12 of the 28 escapes indicate that from the time of the ‘test burn’ or ignition it took 6 hours or less before they were declared an escape or should have been declared an escape (see Tables 1­3). Several more occurred before the ignition phase was complete. Weather changes (winds increased and/or shifted direction and relative humidity dropped over short timeframes) were associated with these events, leading to spotting. However, there are other factors often associated with these events. Many reviews indicated the fire behavior was more than expected or anticipated and burn personnel did not fully realize what kind of fire behavior to expect. Also, the fuel complex either inside or outside the planned boundary caused unexpected fire behavior that was often not addressed in the burn plan. Another connected reason for burn personnel being mislead about what kind of fire behavior to expect was the incorrect selection of fuel model(s) during burn plan development. Fuels models selected for burn plan development often underrepresented fire behavior. Another factor mentioned several times was lighting at the upper end of the prescription which caused prescription parameters to be exceeded often during the peak of the day. However, it was not always a ‘surprise’ to burn personnel that the prescription parameters would be exceeded during the ignition period. Sometimes burn personnel would start earlier in the morning in an attempt to compensate for the expected trend in conditions. However, either the conditions occurred sooner than expected or delays in implementation caused the ignition phase to be ongoing when the conditions exceeded the prescription parameters. Burns were sometimes lit outside of prescription parameters. A final factor was the test fire was not conducted in a representative location. Test fires were conducted in locations that were in cooler or moister locations or conducted in fuels
10 with a different kind of fire behavior than the burn area. At the selected locations fire behavior was lower (lower flame lengths or rate of spread) misleading burn personnel. Commonalities of prescribed fires that were declared an escape the day of
ignition The vegetation­fuel complex played the biggest role as the immediate causal factor in escapes. Several of the escapes noted that increases in fine fuel loading due to seasonal variation ‘surprised’ them. Burn plans were prepared assuming ‘normal’ fuel loading so during execution burn personnel may not have accounted for this influence. One burn boss did note the changed conditions and made some adjustments to holding forces to compensate. However, other factors including not fully appreciating the influences of the fuel type still resulted in an escape. In several cases, the escape occurred during the ‘test fire’ phase. Another noted factor was that spotting occurred early and/or frequently during ignition phase, and in some cases during the test fire or black­lining phase. Spotting, according to some burn bosses, is a common occurrence with prescribed burning.
“A thorough recon of the area surrounding a burn unit is invaluable. Think
about the worst case scenario, and then imagine the worst case going bad,
then go back and plan your contingency”.
Lesson learned from an escape fire review
Commonalities of prescribed fires declared an escape during the patrol and
monitoring phase Weather was commonly reported to have gotten progressively warmer and drier prior to escape. The reviews often cited that the weather was known to be ‘more than normal’ for the time of year. Increased winds or a wind ‘event’ that increased wind speeds for a short period of time contributed to the burn being pushed outside of the allowable burn area. In most cases, the burns were patrolled on a daily basis. In burns of longer duration the patrols noted activity increasing in the burn unit (smokes or open flaming of fuels). In some cases the patrols noted ‘smokes’, but thought they would not threaten boundaries. In some cases, personnel knew other prescribed burns had recently escaped within their geographical area. However, in spite of these ‘signals’ there were no changes in actions such as altering mopup protocols or utilizing heat detecting equipment, etc. In some cases, not having someone directly assigned as the lead for a prescribed fire until declared out caused lapses in awareness of the situation and direction to change procedures. One review provided six useful signals that may indicate conditions are not normal and suggest changes to operational procedures. 1) No significant precipitation in nearly two months. 2) Receiving severity funding just prior to igniting a burn. 3) Fire restrictions have just been lifted for your area. 4) Thousand hour fuels are at or below critical levels (or other levels that indicate they are available to burn) 5) There is a pattern of below normal moisture (precipitation) for more than one year. 6) Trends for dead and live fuel moisture are they at or below long­term averages.
11 Go/No Go ­ It is easier to light a burn than not to light one.
It is easy to let the ‘pressure to produce’ override the signals (ignore them or
don’t look for them) indicating that a burn may not be best executed that day
or even that year.
Other Observations of Repeated Lessons Learned and Recommendations. Many escapes began to take place well before the first spot or slopover. A repeated recommendation for future prescribed burns started with project design and the environmental assessment. Burn block boundaries that were not developed based on known fire behavior characteristics were often a contributing factor in the escape. In some cases, resource specialists selected areas without input for logical or realistic control points. This limits options to successfully implement a prescribed burn or delayed a burn because changes needed to be analyzed and disclosed in an environmental document. Having expertise in fire behavior and practical experience with prescribed fire will help resource specialists to develop ‘logical’ burn blocks. Review teams often cited one key weakness with overall burn plan development. The weakness noted was burn plans for complex burns that did not have sufficient depth and detail to match the complexity of burn. Large­scale burns will likely have multiple aspects, variable vegetation­fuel complexes, resource objectives and constraints that require more complex planning and burn organization to implement successfully. Conclusions and Recommendations The disparate types of information across the agencies made an assessment of this nature challenging, particularly tracking potential knowledge gaps or identifying developing trends, and especially without being able to access all existing reports. Despite this, the collected data do converge on several important lessons that we as a fire community need to learn. These are outlined below. Reviews of all escapes and near misses should be consistently conducted, collected and stored in a centralized location to assist the community in learning from its experiences. A consistent framework with common questions and documentation would help make future lessons learned efforts more meaningful and samples more robust. While individual reviews provide opportunities for the local unit to learn, consistency would better assist this learning across Agencies. Such a consistent interagency framework to conduct reviews of escapes and near misses could assist all practitioners and agency administrators to identify knowledge gaps. As Weick and Sutcliffe (2001) recommend, sharing of near misses may tell us more about reliability than escapes, but they also provide us the opportunity to ensure that we take signals as a sign that things are ‘ok’ or ‘not ok’ until proven otherwise The NWCG Complexity Rating System Guide should be explored to look at how to handle cases where burns are simultaneously lit potentially changing complexity, management oversight and organization structures. Is it true we underrate complexity? If so, why and in what context? Is there a tendency to underrate overall complexity or individual elements – risks, potential consequences and/or technical difficulty ­­ because experience with particular situations is low so it is not recognized as a potential source of problems?
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Is there a tendency to underrate because adequate resources and skill levels are not available to the unit (e.g. a hesitancy to identify a burn as more complex because an RxB2 or RxB1 is not on the unit or readily available). There maybe a gap between the intended use of the complexity rating system and policy. Per policy, a final complexity rating is to be done and included in the signed burn plan. This freezes the rating for implementation. There is no mechanism or direction to aid burn personnel to reevaluate overall complexity or trigger the need to increase the level of detail in burn plans when multiple plans are implemented at the same time. Vacancies in key positions were noted in several reviews as having an important impact on fire operations. The recommendation in the reviews was to fill vacant positions to help relieve the stretched workforce experiencing expanding programs. We continue to be surprised by fuels and fire behavior. Why? Have we lost our knowledge base and skills in identifying the carrier of fuels and selecting the most appropriate fuel model? Or, are we dealing with vegetation­fuel types that are more complex or different than we have experiences with or fuels models to represent? Likely, both of these issues are causes as well as others. Due to limitations of the models to reflect reality practitioners may be reluctant to use these tools. Even with the limitations of fuel models and fire behavior modeling these tools assist with identifying sources of problems. However, continued training in usefulness and shortcomings of fuel and fire behavior models may help prescribed fire planners. Other specific recommendations include:
·
Continue to share lessons learned with other fire management personnel to broaden experiences levels.
·
Investigate mechanisms to minimize possibility of escape the day of ignition. For instance, checking fuel receptivity outside the unit may be as important as how it burns inside the perimeter. Test all fuel types. If there is more than one fuel inside or outside the planned boundary we should be aware how each of these are going to respond. Holding and contingency forces then can be ramped up or down accordingly.
·
Monitor leadership assignments and personnel transitions closely to ensure someone is directly assigned as the lead for a prescribed fire until the fire is declared out. Next Steps to Become a HRO Achieving and maintaining high reliability requires not just intellectual understanding, but translation of this into practice. This review of reviews has not revealed any earth­ shattering weaknesses; all weaknesses summarized above have been known previously. What it has done is to further highlight several trends and points of weakness in our practice. How do we move forward from here? This section is included in the hopes that it will stimulate further discussion…and actual change in our practice. ‘Reviews’ need to be approached as a tool for learning and be clearly separated from disciplinary actions. Did you have a good plan? Did you follow the plan? Did you execute it with qualified people? These are all good accountability questions. However,
13 accountability and learning from undesired outcomes are often at odds with each other. Accountability can lead down a path of blame after which opportunities for learning disappear. If fire use practitioners are going to move toward becoming a learning organization then we have to examine our ‘failures’ as an HRO. Reviews for learning should use questions that help evaluate expectations, assumptions, surprises and blindspots. Further develop and integrate efforts exploring how to become a learning organization and operate consciously use the principles of a High Reliability Organization. Efforts so far include conducting After Action Reviews and Managing the Unexpected workshops. Both of these have been useful pathways to explore and should be developed to further integrate these concepts into daily practice. Agencies need to further explore/validate the emerging trends such as a tendency to ‘underrate’ complexity, look at why this is happening and what we need to overcome that tendency. Another area that may need further work is to look at why some vegetation­fuel complexes seem to repeatedly ‘surprise’ practitioners especially the more flammable fuels like cheatgrass and pinyon­juniper. Another area that seems to be a struggle is for practitioners to recognize risks and develop burn plans for complex landscape scale burns. One way to overcome this tendency is to encourage burn plan development by a team (prescribed fire planner, burn boss, holding and ignition specialists) because more eyes, and more experiences will be added to the preparation of the plan. How can we avoid being blinded by burn plans (Weick and Sutcliffe 2001)? Federal land management policy requires burn plans. How can we strengthen their use? One option might include drawing on concepts from Managing the Unexpected,. A team could explore ways to overcome the trap of expectations and tendencies to seek confirming evidence. For example, increasing awareness through NWCG courses that burn plans could blind us (how and why does that happen?). Another possibility to consider are ways to develop burn plans with a balanced approach ­­ focus on what we do not want to have happen as much as we focus on what we do want to have happen. It could be stressed to prescribed fire planners they should focus on ways to look for ‘disconfirming’ evidence that they are not in prescription and put them in the monitoring plan. Since it is the policy of federal land management agencies that burn plans are required this area would warrant further exploration. Agencies should look into ways to build line officer and agency administrator ‘sensitivity to operations.’ Only two of the most recent reviews explored and acknowledged the role of the agency administrator. One case commented on the active role of the agency administrator, but also noted they had not yet attended a mandatory training (i.e. Fire Management Leadership). The other case praised and acknowledged the active role of the agency administrator who was on­site while the burn was being conducted and played a keyed role once the prescribed fire had been declared an escape. Agency administrators will play a key role in operating as a HRO. Acknowledgements Intermountain Region (R4) FAM, particularly Dave Thomas, Regional Fuels Specialist for promoting learning organization, supporting and funding a detail program analyst to the Wildland Fire Lessons Learned Center to develop this analysis.
14 Tim Sexton, National Fire Use Specialist, Forest Service and Al Carrier, National Fuels Management Specialist­Operations, Bureau of Land Management for digging into their files and supplying additional escape prescribed fire reviews not electronically available. This report is intended to further the mission of the Wildland Fire Lesson Learned Center: Collect and analyze observations Share lessons learned and best practices, and Archive knowledge and information.
15 References and Citations Garvin, David A. 2000. Learning in Action: a guide to putting the learning organization to work. Harvard Business School Press. 256 pages. Keller, Paul. October 2004. Managing the Unexpected in Prescribed Fire and Fire Use Operations – a workshop on the high reliability organization. RMRS­GTR­137. 73 pages. National Wildfire Coordinating Group. 2004. Prescribed Fire Complexity Rating System Guide. NWCG NFES 2474. 45 pages. Snook, Scott A. 2000. Friendly Fire: the accidental shootdown of U.S. Black Hawks over Northern Iraq. Princeton University Press. 257 pages. Weick, Karl E, and Kathleen Sutcliffe. 2001. Managing the Unexpected – assuring high performance in an age of complexity. 200 pages.
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Table 1 Timeline of Escaped Prescribed Burns Involving Fine Fuels (Grass and Grass-like) Vegetation-Fuel Complexes. In three out of five escapes, the fine fuels were
not the targeted vegetation for burning.
Burn
Date
Fuel
Time
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
Blacklining at upper end of prescription window. Plan written for normal conditions, but conducted with “abnormal” level of fully cured
cheatgrass. Burn boss limited experience with fuel type.
During
initial
blacklining
Pa-CA
June 22,
1998
Cheatgrass
No chronology provided
Two spots occurred “shortly after ignition. First spot contained. Second spot grew to 4 acres and prescribed burn declared an escape.
Holding actions limited due mechanical failure of helicopter.
BQ-CA
July 1, 1998
Heavier
loading
cured grass
“shortly
after
ignition”
1235 test ignition Declared ?
Had no lookouts posted to look for spots. While more than the minimum holding forces were on-scene unable to respond quickly to
slopover due to hindered access. Burn boss limited experience with fuel type.
Me-UT
Sept 9, 2004
Cheatgrass
During
“test
“burn”
1545. 1602 1625
IL-AZ
February 4,
2004
Reed Grass
Main ignition of unit began 15 minutes after test burn. Ignition stopped after 50 minutes. Possible spot across river was reported and
confirmed in 5 minutes. Holding forces were unable to locate and control spot immediately due to thick smoke and access was also
hindered.
Less than 2
hours
0945..1000…1050 1110 1115
Prepared by D.Dether
June 2005
1
Table 1 (cont) Timeline of Escaped Prescribed Burns Involving Fine Fuels (Grass and Grass-like) Vegetation-Fuel Complexes.
Burn
Date
Fuel Type
Time
LR-CA
July 2, 1999
Invasive
weeds
Less than 3
hours
0800
0900
1000
1100
1050
Prepared by D.Dether
June 2005
1200
1200
1300
1400
1500
1600
1700
1300-20..1330
2
Table 2 Timelines for Escaped Prescribed Burns Involving Shrubland/Woodland Vegetation-Fuel Complexes.
Burn
Date
Fuel Type
Time
Bl-WY
June 4, 2003
Pinyon/
Juniper
3 hours
0800
0900
1000
1100
1200
1200
1300
1400
1500
1600
1700
1245- 1300..1345………………1500
Main ignition of one area began 10 minutes after test burn. Approximately 1 hour later, ignition began in a second area away from the
first. Multiple spots occurred some with rapid rates of spread. Test burn was not conducted in representative location.
Ca-UT
Sept 23,
2003
Heavy, oak
brush
5 hours
1230 1240
1320
1430
1515
1630
1700
Prescribed burn not declared an escape when it should have been.
SC—
April 10,
2003
Decadent
bitterbrush
& P/J
IB-FL
March 2,
2004
Southern
Rough &
swamp
5 hours
1130 1200
1400
1640
Not declared an escape unit 5 days after ignition, but review determined the prescribed fire should have been declared within 3 hours of
ignition due to fire behavior being outside of prescription parameters. No documentation of test burn.
Less than 3
hours
Prepared by D.Dether
June 2005
Est. 1100
1400
3
Table 3 Timeline of Escaped Prescribed in Forested and Slash Vegetation-Fuel Complexes. While most escapes in these vegetation-fuel complexes occurred days after
ignition during the patrol and monitoring phase; however, several did occur during the ignition phase with two declared an escaped prescribed fire within six hours.
Burn
Date
Fuel Type
Time
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
No mention of when test fire was conducted but lit in an area not representative of fuel conditions. Initial spot fires handled by holding
forces.
Pi-NM
March 12,
1996
Ponderosa
pine, mixed
conifer &
P/J
Less than 2
hours
NR-UT
June 28,
2001
Slash w/
subalpine fir
Less than 5
hours
LJ-AZ
May 5, 2004
Ponderosa
pine & P/J
Same day
as ignition.
Unknown
start time.
1130
1230 1300 “shortly after 1300”
1300
Unknown
1100
1143
1400
1500
1600
1645
1736
1517
Ignition was planned for and stressed during briefing the need to be completed by 0900 hours due to observed burning conditions. Ignition
was not completed within timeframes due to logistical and mechanical problems.
Prepared by D.Dether
June 2005
4
Prescribed Fire Escape Reviews
Project Name
Lizzie Springs
Pinatosa
Banner Queen
Yr
Agency
1996 BLM
Unit
Rock Springs
District
1996 FS-R3
Mountain Air
RD, Cibola NF
1998 BLM
El Centro
Resource
Area, California
Desert District
Prepared by D.Dether
Forest Fuels Planner, Boise NF
State
Planned Acres
WY
Not Reported
(NR)
NM
Total 9,000 in
project, approx.
5,100 ac actually
burned w/in
planned area
CA
650
Escape Size and
Consequences
Complexity
Rating
350, unknown if
these acres were Not Reported
outside unit or total (NR)
ac burned
2,000 acres
unplanned
including 300 ac
pvt
NR
High - aerial &
hand
Appendix A
Veg/Fuel Complex
Conifer including
heavy subalpine fir
timber with aspen.
Not Reported
More fine fuel due to (NR)
2 yr rest from
grazing.
Multiple - ponderosa FM 9 & 10.
pine, mixed con & Used FM 10 for
P/J, oak shrub
BEHAVE runs.
Mature chaparral
(chamise) w/ unusual
amount of grass due
to unusual amt of ppt
with el Nino.
NR
1
FBO Fuel
Model &
Modeling
Season of Ig
(mo/day)
Oct 2-4
12-Mar
Used brush
model, but did
not account for
1-Jul
amt of grass
and dead/live
ratio in brush
Length of time from Test Fire or Ig
to being declared an Escape
8 days
1.5 hours No mention of test fire.
Hand ignition began ~1130 hrs. Spot
fires noticed between 1230-1300 by
hand ignition crew, but able to control
with holding resources. RxB fired main
ridge inside unit with PSD; however fire
spread downhill rapidly towards
perimeter. Shortly after 1300 declared.
"shortly after" ignition. First ignited
(test burn) @ 1235 hrs. Shortly after
ignition two spot fires occurred. 1st
spot was contained. 2nd spot grew to
2 acres then 4 acres getting into steep
terrain and not safe for ground forces.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Yr
Agency
Unit
State
Complexity
Rating
Veg/Fuel Complex
22-Jun
Grass, oak brush &
riparian veg.
Forested outside
2-Jul
<3 hrs. Test fire @ 1050 hrs. Multiple
spots at different locations. Declared
@ 1330 hrs.
Juniper
18-Aug
NR < 1 day. No chronology included
NR
CA
100
2,000 including pvt
Low
+ 23 homes
ID
NR
NR
1998 BLM
UT
Lowden Ranch
1999 BLM
Redding Field
Office
Wilson Gulch
(missing append)
1999 BLM
Burley Field
Office
NR
NR
2
Length of time from Test Fire or Ig
to being declared an Escape
< 1day no chronology included. Spot
fires or slopovers that were more than
holding forces could handle was one of
noted factors.
Blacklining
Pahcoon
278
Season of Ig
(mo/day)
29-Apr
Cheat grass with
heavy "above
normal" loading
Cedar City
District, Dixie
Resource Area
OR
FBO Fuel
Model &
Modeling
5 hrs. Firing began in NW corner ~
1130 after briefing. 1230 began having
problems w/ spotting. 1300 stopped
firing and took holding actions in NW
corner. More spots along N-side line
@ 1430. 1530 one acre outside unit
on pvt ground. 1630 declared an
escape.
NR
Klamath Falls
Resource Area
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Escape Size and
Consequences
10 acres inside unit
plus 29 acres on
NR
Pvt - timber lands
1998 BLM
Fox Lake
Planned Acres
Appendix A
NR
NR
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Cerro Grande
EB-3
Mt. Como
Yr
Agency
Unit
2000 NPS
Bandelier NM
2000 BLM
Arizona Strip
Field Office
2000 BLM
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Carson City
Field Office
State
Planned Acres
Escape Size and
Consequences
Complexity
Rating
Appendix A
Veg/Fuel Complex
NM
Three phase
48,000 plus pvt w/
project. 1st of 3. 280+ home/
Moderate - hand Multiple
Approx. 900
structures
AZ
3 acres "test"
subunit
NV
197 acres
Damaged pvt
property
Multi-unit project.
1st burn in 1997. NR
EA done 1996
NR - a burn plan
was not
NR
prepared for this
"test" unit
NR - Elements
rated as "high" Pinyon with litter/duff
missing rationale & brush that provided
and mitigations. ladder fuel
Hand ignition
3
FBO Fuel
Model &
Modeling
NR
Season of Ig
(mo/day)
Length of time from Test Fire or Ig
to being declared an Escape
4-May
1 day
Ignited
3/31/2004.
Declared
4/13/04
13 days.
2 days Had 11 people & 2 engines to
hand ignite area, but no direct access
to unit for engines. Ignition went well,
Oct 18
but fire burned into the evening &
Started Ig 1325
actively backed down hill all night.
Done by 1700
Next day no new ignition & tried to
Oct 20 Declared
contain area already lit. A forecasted
1645
wind event kick up fire & spotted
outside of unit from unburned island
inside unit.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Yr
Agency
Unit
State
Planned Acres
Escape Size and
Consequences
Alkali Rim
(Near Miss)
2001 BLM
Worland Field
Office
WY
1,200 to 1,500
N/A.
This review was
about the need to
use escape routes
during burn ops.
Cordgrass (escape
named Pin Oak)
2001 FWS
Marais Des
Cygnes NWR
KS
80 acres
13.6 acres w/ 4
acres on pvt
Navajo Ridge
North Shore Kenai
Lake (Draft)
2001 FS-R4
2001 FS-R10
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Dixie NF
Chugach NF
UT
AK
Complexity
Rating
Appendix A
Veg/Fuel Complex
Season of Ig
(mo/day)
Length of time from Test Fire or Ig
to being declared an Escape
Low, but did not
follow agency
Juniper with
policy. Should sagebrush/ grass
have been
intermixed
Moderate
N/A
20-Sep
N/A
Low
FM 3 inside
FM 3 & 9
outside
28-Oct
11 days
28-Jun
4.5 hrs. Test burn conducted @ 1300
hrs w/ no holding problems. Ignition on
unit occurred from 1400-1500 hrs. Ig
stopped due to spotting, holding crews
contained and Ig resumed @ 1700 hrs.
At 1730 hrs, more spotting occurred
and several slash piles were ignited.
Declared at 1736 hrs. Contained 2000
hrs.
5-Jun
10 days. Area was monitored &
patrolled according to the plan.
Evening of 6/25 spotfires outside of
unit discovered. Increasing winds
caused spotfires to spread beyond the
capability of local resources.
cordgrass
Project 199, mult.
units. 26 ac w/ 2 8.2 including pvt
units previously lit
NR
1,000
Reported
"complex" no
Bug-killed spruce
doc. of analysis aerial ignition
NR
FBO Fuel
Model &
Modeling
Lopped slash w/
subalpine fir and
aspen outside units
4
Not Reported
(NR)
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Pot Creek (DRAFT)
Rock
Wilson
Anderson/ Danskin
(this review covers
2 separate burn
project areas)
Yr
Agency
2001 BLM
2001 FS-R5
2001 FS-R1
2002 FS-R4
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Unit
Craig Field
Office
Tahoe NF
Lolo NF
Boise NF
State
CO
CA
MT
ID
Planned Acres
Black lining with
261 ac area
200
706
3,500
Escape Size and
Consequences
250 - 300 acres.
Suppression cost
$50.0 ths.
201
Complexity
Rating
NR
NR
none outside
High - aerial
planned boundary ignition.
405
High - aerial
Appendix A
Veg/Fuel Complex
FBO Fuel
Model &
Modeling
Season of Ig
(mo/day)
~3 hours. Test fire completed by 1315
hrs. Ignition began around 1330 hrs.
A "significant wind event" occurred
1525 hrs. w/ winds out of the west at
30-40 mph driving the fire across the
east line. Winds reported to begin
dying down around 2300 hrs.
Sagebrush
NR
Long needle
pine/white fir
5 hrs. (2nd day of Ig) Test fire @
0715 hrs. Ignition started @ 0800 hrs.
FM 9 in, FM 10
RH drop dramatically bwtn 0800-0900
May 9th part of
outside.
hrs, but still in prescription. 1030 hrs.
unit successfully
Continuous
RH drops to 19%. 1100 hrs RH 12%,
ig. May 10
frost-killed
winds increase to 5 mph. Contingency
proceeded to
brush @
forces called. 1130 numerous spots,
complete ig
escape
more resources ordered. 1222 hrs
more spots which grew, more
resources ordered. Declared 1230.
Dry timber types,
mostly northerly
aspects
FM 2/10/9. FM
selection not
issue.
Smoldering in
Lrg 1000 hr
fuels was
PP/DF intermixed w/
sagebrush/ grass
5
4-Sep
Length of time from Test Fire or Ig
to being declared an Escape
Four different
days for
ignitions. April
25-26, May 9
and May 11.
Declared an
escape May
24th.
29 days. Declared an escape due to
"logistical and financial" concerns. The
burn was NOT outside planned
boundaries.
15-May
4 days Two different landscape scale
burns ignited the same day. Both units
had previous ignitions weeks before.
Snow remained on northerly slopes
and checked surface spread of fire.
High winds (30-35 mph) from a passing
system caused both burns to escape
planned boundaries at the same time.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Yr
Agency
Sanford (this review
covers 2 separate 2002 FS-R4
burn project areas)
Blanco
Cascade II
Cherry
2003 BLM
2003 FS-R4
2003 FS-R3
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Unit
Dixie NF
Albuquerque
Field Office
Uinta NF
Prescott NF
State
UT
NM
Planned Acres
3,500 total in 2
separate RxB
NR
Escape Size and
Consequences
78,000
NR
Complexity
Rating
Appendix A
Veg/Fuel Complex
FBO Fuel
Model &
Modeling
Season of Ig
(mo/day)
Two separate
days of Ig on
two different
burns 11 miles
apart. April 22,
May 13
NR
Low
UT
1,000 (in BP)
Ignited 400 not in 7,828
BP
High
AZ
Project 8,141 2nd 150 ac slopover +
of 3
992 ?
NR - hand &
aerial
6
Ponderosa Pine but
w/ significant P-J
Heavy, mature oak
brush intermixed with
aspen
Chaparral
Incorrect FM
selection - used
FM 8. Review
recommended 4-Jun
using a
combination of
FM 4 & 6
Length of time from Test Fire or Ig
to being declared an Escape
30+ days
3 hrs. Test fire 1200 hrs - 2-4' FL with
occasional torching. Ig stopped 1245.
1300 hrs spot fire reported on top.
1345 hrs burn personnel unable to
contain. Declared 1500 hrs. ~16001700 hrs more resources ordered
(engines, tanker, T-1 crew).
23-Sep
5 hrs. Test burn @ 1230 hrs. Second
ignition in different location 1320 hrs.
Spots occurring in 3 different locations
@ 1430 hrs, 1515 hrs & 1630 hrs.
Declared 1700 hrs. 1720 hrs holding
forces retreat to designated safety
zones.
16-Jun
1 day. Ignited 6/16. "Unpredicted wind
event" shifted wind direction. 150 ac
spot occurred and contained. 6/17 no
new ig., mopping spot. New spot 6/17
@ 1300 hrs.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Yr
Agency
Petty Mountain Near
2003 FS-R4
Miss
Puma
Sink's Canyon
2003 FS-R2
2003 BLM
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Unit
Ashley NF
Black Hills NF
Lander Field
Office
State
UT
SD
WY
Planned Acres
1,000
Escape Size and
Consequences
Veg/Fuel Complex
FBO Fuel
Model &
Modeling
Fuel Model 8
covered 80Primarily Sagebrush 90% of area
w/ aspen
with isolated
pockets of FM
10.
Not declared (Total
NR
ac burned 2,593)
Project 800 w/ 11
units. Completed
231 acres on 2
NR
units prior to
lighting another 2
units that escape.
NR
Complexity
Rating
Appendix A
Low - hand BB.
Reviewers
questioned
whether RxB3
Ponderosa pine
was correct
"management
oversight"
Rated Moderate WUI. According Majority NR,
12.76 acres outside
to BLM 9214 all decadent bitterbrush
MMA on PVT
WUI should be & P-J
rated High
7
Season of Ig
(mo/day)
24-Sep
Length of time from Test Fire or Ig
to being declared an Escape
Was not declared an escape.
1+ days? Had been "blacklining" on
one of units during two previous times
in March. March 31st continued
Blackline Unit 3
blacklining on one and started on
March 14 & 25,
another unit. During interviews, burn
Ig on Unit 3 & 5
personnel mentioned holding/spotting
March 31. April
problems. No holding or monitoring
1 Ig & declared
overnight. Declared April 1st after fire
behavior increased & made significant
runs inside and out of target units.
Majority FM 2,
FM 6 not used
in BP to
10-Apr
account for
brush inclusion.
5 hrs. Test ig @ 1130. 1200 hrs
blacklining started. 1400 hrs ig of
interior. 1640 hrs winds switch, RH
drop & spots across line. Not declared,
but later determined outside of MAA.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Impassable Bay
(Compartments 16
& 117)
Island Lake
Long Jim III
Yr
Agency
2004 FS-R8
2004 FWS
2004 NPS
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Unit
Osceola RD,
NF's of Florida
Imperial NWR
Grand Canyon
NP
State
FL
AZ
AZ
Planned Acres
Escape Size and
Consequences
Complexity
Rating
Appendix A
Veg/Fuel Complex
Individual burns
rated low, but
burned together
(adding
helicopter &
other mixed
1,500 in two units
resources)
32,000 + including
Long-leaf pine &
16 = 1,000 117 =
indicated should
state & pvt lands
"swamp"
500
have been
Moderate to
High. No
documentation
on "final"
complexity
rating.
630 acres
Project 5,050.
1st of 3 for 1,618
Estimated 200
acres
Moderate
NR - one
element of
analysis was
raised as an
issue
8
FBO Fuel
Model &
Modeling
Season of Ig
(mo/day)
Length of time from Test Fire or Ig
to being declared an Escape
FM 7 (southern
Rough) and FM 2-Mar
4 (dry swamp)
5 days before "officially" declaring an
escape, but approx. 3 hours after
ignition the burn was out of prescription
& should have been declared. A test
burn was conducted, but not
documented. Estimated from report to
have been around 1100 hrs. At 1400
hrs obs flame lengths of 20',
(prescription called for 4-6') which
exceed prescription.
Fuel model 3.
Cattails (8-10 ft),
Appropriate
phragmites (common model selected
reed, 8-10 ft) also
but under 4-Feb
intermixed with salt estimated
cedar
potential fire
behavior
< 2 hours. Test fire @ 0945 hrs. Fire
behavior and smoke Rx met. Ig begins
@ 1000hrs. At 1030 hrs. east flank
widen w/ aerial ig. At 1040 hrs
remaining unit lit in 2 passes. 1050 ig
halted. 1105 hrs possible spot across
river. Confirmed 1110 hrs. Declared
1115.
Ponderosa pine w/ PJ FRCC 3
Ig time NR, but aerial ignition
completed 1100 hrs. Spotting reported
@1143 hrs. Declared @ 1517 est. 6+
hrs. Ignition was to be completed by
0900 hrs due to observed burning
conditions during blacklining ops a
week before and during test ignition
that day.
5-May
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Meadow
Mitchell & Hot Air
(this review covers
2 separate burn
project areas)
Yr
Agency
2004 BLM
2004 FS-R3
Prepared by D.Dether
Forest Fuels Planner, Boise NF
Unit
Fillmore FO/
Fishlake NF
Clifton RD,
ApacheStigreaves
State
UT
AZ
Planned Acres
200 acres. Prior
burning in spring
on same project.
500 ac in project.
Escape Size and
Consequences
Complexity
Rating
524 acres. Only 2
inside unit.
Included PVT &
state land. Closed NR - RxB2 with
hwy due to smoke. hand ignition.
Burned power
poles, cut power to
town.
Planned 5,000 to
1,537
7,000 acres
Appendix A
Veg/Fuel Complex
Sagebrush with
cheatgrass & thinned
P-J. Increase fuel
loading of cheatgrass
at time of burn.
Individual burns
Low - Mod. Ig
together should
Multiple types
have raised
including ponderosa
complexity.
pine. Others not
Also, content of
mentioned.
complexity
analysis found to
be lacking.
9
FBO Fuel
Model &
Modeling
Season of Ig
(mo/day)
9-Sep
Fuel model 8
was used for
complexity, but
prescription
parameters
used more
12-May
volatile fuel
models 4 & 9.
Spotting
distances were
not calculated.
Length of time from Test Fire or Ig
to being declared an Escape
< 1 hour. Test fire Ig 1545 hrs. Two
engines released to respond to wildfire
1550 hrs. Decision to "shutdown" and
suppress test fire. Spot fire noticed @
1602, within ~8 minutes spot grows to
30 acres. Declared @ 1625 hrs.
Winds increased & shifted with T-storm
activity. Spotting
6 days Concurrent ignition on two
separate projects. First planned
ignition delayed due to high wind
assoc. with weather front passing.
Begin ground ignition next day.
Following day proceeded with ignition
by hand & aerial.
6/29/2005
Prescribed Fire Escape Reviews
Appendix B
Project Name
Anatomy of the Escape - What were the "weak signals"
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Lizzie Springs
Appeared to review team to be "well planned and properly executed, but inadequately
documented." Knew the head of Lizzie was problem area - fuels and no natural barrier. Two
other burns "successfully completed" after this burn, but several days after this burn was
ignited two other burns in the state escaped and local personnel knew of these escapes.
During 1996 "drought" conditions existed affected heavier fuels more than normal, area was
known to have heavier fuels. On the 8th day, the fire escaped "due to high wind event", but
it seems that many signals were potentially missed.
Burn Plan based on "normal conditions" yet burn personnel proceeded with plan and did not
make "adjustments" to burn plan or operational procedures even knowing that there was
"heavier than normal" fine fuels and with drought conditions that the heavier fuels could be
effected even though they knew the area had heavier fuels. They knew the Wx was
"unusually, warm and windy". Patrolled for 5 days and even with smokes still in unit assigned
resources to other burn projects. There was a shortage of "qualified" personnel and this
contributed to inadequate mopup & patrol. The key people involved were "fully trained &
experienced", but their numbers were barely adequate to execute a single burn let alone
multiple projects.
Pinatosa
Shades of Cerro Grande - Snow delayed initial ignition. Spring time with public "knowing"
about strong, erratic winds. In this case, technically lit outside of prescription elements
and/or shortly after ignition the Wx conditions exceeded prescription. The report mentions
that the test fire location used during hand ignition was not representative of fuels or
environmental conditions (more shaded and sheltered than unit). Many problems with burn
plan and prescription development. Burn plan preparer not qualified nor very experienced.
RxB not experienced with burning in these fuel types. Trust with Wx Service was low
because of earlier "blown" forecast that did not predict snow storm which caused a delay.
In this state (NM), there may be a need to better understand seasonal patterns of winds or
wind events during transitional seasons. Wind and Wx patterns in general need to be
understood locally, seasonally and what effects larger Wx influences can have on a burn.
This burn is approx. 80 air miles from Cerro Grande. The review noted that the burn boss
(although qualified) did not have experience of the with fuels types & may have contributed to
practices leading to the escape.
Banner Queen
One of two burns involving use of a contractor - other burn was Fox Lake. The review noted
that the burn plan was well developed and prepared. The execution of the burn was done
well and going well. Two things directly linked to escape although was not giving enough
consideration to fire effects of the grass component in the predominate brush models used
(with high live to dead ratio). The grass component repeatedly came up in interview (a
surprise to burner?). Knew it could be a problem, but focus was on the brush not fully
appreciating what the added grass would do. Experiences with wildfire that year may have
misled personnel into believing spread would NOT be a problem. The burn plan did not
reflect changes in fuel structure so not planned for with the test fire. 2nd Helicopter
malfunction was also mentioned as a direct cause of escape because it was not able to help
ground crews suppress second spot when it got into steep ground.
One lesson learned raised here concerns mechanical failures. While redundancy in human
systems may not work well, redundancy for mechanical devices does work. When
mechanical equipment is key to burn operations and/or holding capacity it may an area to
consider and make sure your contingency plan covers this such as having another helicopter
with suppression capability on standby-by for quick response. The complexity of the
vegetation-fuel complex surprised burn personnel. Also, previous experience with wildfires
that year may have "signaled" to burners that this fuel combination was more "flammable"
than believed. Local manual direction DID NOT reflect current national direction.
Supplemental burn plan was NOT signed by agency administrator.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
1
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Anatomy of the Escape - What were the "weak signals"
Appendix B
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Fox Lake
The review noted that the contractor did not transition quickly enough from firing to holding.
Did not take on-site 10-hr dead fuel moisture samples nor requested a spot weather as
This is the only escape that involved using a contractor which prepared and conducted the required. Used only general zone forecast. Weather obs. from on-site indicated parameters
burn. The review determined the burn plan was adequate and all people including the
were near the drier end of the window when ignition was started & conditions seemed to be
contractor were qualified. However, contractor did not sample fuel moistures outside of unit out of prescription quickly. All ignition had been stopped and in holding mode when out of
on PVT where it was more open therefore drier. Lit on "drier" end of Rx. Lighting too much prescription parameters. The morning of the burn unit was selected over another because
too fast was noted as a contributing factor. Contractor also did not get spot Wx forecast as the other unit was "too wet" (unknown if this influenced burn boss assumption that is unit
required in burn plan. The review noted that since contractor is "paid by the acre" that this would not cause concerns with control, not raised as an issue in report). On-site weather
may have played a role in choices to proceed with ignition. There was "prolific" spotting
obs. were not taken in a representative area of conditions (winds taken in sheltered area,
which combined into 3 "major slopovers" outside unit all onto pvt ground.
area that was source of spotting was in near an exposed ridgeline). Also, recommended that
10-hr needed to be monitored at least a day prior to ignition and if conditions outside of unit
are different those areas should also be monitored.
Pahcoon
Review noted that all burn personnel were qualified for their position, but noted that
The review concluded that there was a "failure to adjust operational procedures" to reflect
experience in Rx fire and in this fuel type varied considerably. The lack of expereince in this
the additional on-site fuel loading and an attempt to black line on the "extreme upper end of fuel type of the burn boss was noted as a contributing factor. Burn plan was written for
the prescription". The plan was written for "normal" conditions, but that year there was
"normal" conditions, and noted it is up to burn personnel to adjust when conditions are
"above normal" ppt so "heavy" loading from cheat grass was created. RxB did note the extra different than planned. Recommended that for burns with considerable "blacklining"
grass and added engine and "pumpkin" to compensate. RxB had little experience in this
operations to write seperate prescriptions parameters (Note: this is currently in BLM policy
type. Brush component was above "optimum" (i.e. wet or high live fuel moisture), but grass and burn plan templates). Inter-office coordination also needed to improve as well as
fully cured.
communication & cooperation with other agencies. Burn was adjacent to an Indian
reservation, but when escape occurred they were not notified of escape.
Lowden Ranch
Two firing crews. 1115 RxB concerned abut fire getting into trees, but holding actions
mitigated concern. 1145 RxB (T) reported "good progress" and asked if should continue.
Given Ok from RxB. 1200 hrs RxB(T) noticed spots. Ig stopped, holding action contained
There is extensive documentation on this escape so it was not summarized here at this time.
and 100% mopup was proceeding. Ig resumed @ 1220. At 1300 hrs spot reported in area
of initial concern and it was also contained. 1320 hrs 3rd spot spread quickly and exceeded
holding capability.
Wilson Gulch
(missing append)
Burning in juniper necessitate wide parameters (RH, temperature, live fuel moisture, and
wind speed/direction) that would be considered "high". Based on some of the
recommendations it appears this burn used a combination of blacklining and "nighttime"
recovery for containment lines. The review only mentioned that one night did not get
expected recovery. Also, based on review team recommendations it seems that burn
personnel were not involved in the upfront (during NEPA) planning and selection of the area
to be burned. Also, the NEPA document and analysis did not allow for use of dozers which
limited options for the burn personnel to implement.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
2
Missing documentation may have had additional information mentioned in report. Need to
have all pertinent information in reviews (this review talked more about what the review team
talked about than providing the content and context of their discussions). The review
seemed to indicate testing a newer approach to burning that would have benefited others to
have more information and share results with other burn personnel. Importance of having
prescribed fire experience at the planning table to help with project design, allowable burn
areas and to ensure activities or practices that will likely be employed during burn operations
(e.g. use of dozers) are appropriately analyzed and disclosed in the NEPA document.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Cerro Grande
EB-3
Mt. Como
Anatomy of the Escape - What were the "weak signals"
Appendix B
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
There is extensive documentation on this escape so it was not summarized here at this time. There is extensive documentation on this escape so it was not summarized here at this time.
The review attributed the escape to "failure to adjust operational procedures (holding and
mopup) to reflect the changing weather conditions. Available fuels during ignition included
only the upper needle cast which was dry & consumed. Duff layer was wet and not
consumed. Large fuels (logs) were not consumed. Fine fuels (<3") were reduced by 6070%. 1st and 2nd weeks after ig, units each checked each day. Smokes were obs, but
minimal mopup occurred due to " test" nature of the burn. Into 1st week after ignition,
agency's unit suspends any new ignitions because weather conditions "became too dry".
The day prior to the escape, patrol notes smokes and open flame in unit, but did not think
there was a risk of escape. The day of escape patrol noted smokes in unit and also did not
think it posed a significant risk of escape. Seven hours later "significant smoke" was
reported in the area. Leadership (Officer manager, FMO, FCO out of town), the RxB in
office, but doing other work. General weather forecast for that day call for temps in mid-70's,
RH's in teens and SW winds 20-30 w/ gust to 40 mph.
Small burn, testing a "technique" for larger application. Did not constantly staff burn nor had
an individual directly responsible for burn until declared out. Were personnel lulled into
complacency since it was a small (3 acres) test unit? Trust (lack of confidence) in weather
forecasts was mentioned in report, but not cited as a reason contributing to the escape. The
"burn plan" used (the test unit was not included in it) did not have "triggers" identified for
mopup or contingency actions. Technically, there was no burn plan for this test burn.
There were no natural barriers or line constructed in places to contain burn area. Potential
fire behavior was noted in the complexity analysis as a significant issue, but no specific
Review recommended that for burns which rely heavily on weather conditions for containment
mitigations were identified. Burn containment relied heavily on nighttime recovery to control should consider using portable RAWS. Also, no nighttime Wx obs were taken and provided
burn spread. This coupled with 6 listed "indications" noted in review that conditions were not to NWS. Another recommendations noted concerning coordination w/ NWS and on-site Wx
"normal". 1) no significant ppt. from 8/30 to 10/20. 2) this agency's unit had been receiving obs procedures that should be taken. One other burn (WG-ID-99) also had similar problems
"severity" funding until just prior to burn. 3) fire restrictions had just been lifted for this area. with a prescription that relied on nighttime recovery to contain burn, but did not get recovery
4) 1000-hr TLF @ 6% 5) in 2nd year of "drought". 6) at established monitoring sites Pinyon nor took measures to record & work with NWS to improve forecasts. (Note: this burn review
pine live fuel moisture was EQUAL to long-term avg. & for shrubs substantially BELOW long- might be a good example to illustrate the concept of "less decision making and more senseterm avg. Also noted contributing to problems were fuels - "a substantial portion of the stand making".)
had a litter/duff layers & ladder fuels not "normally" associated with pinyon stands.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
3
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Alkali Rim
(Near Miss)
Anatomy of the Escape - What were the "weak signals"
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Review determined that all personnel were qualified for their positions, but for some it was
their first time on a burn and where not directly supervised at the time of the incident.
This is a good example why evaluating and sharing "near misses" are important and valuable
Topography where incident occurred was "steep" (30-40%) with thick fuels - closed canopy
tools. Good reminder that prescribed fires are just as difficult as a burn out operation on a
juniper. Crew was instructed to light at the bottom of this drainage to generate heat to get
wildfire and LCES should also be in place for Rx fires. This had the potential to turn out very
the unit to burn better. The burn crews had been having a difficult time getting area to burn
badly with possible injuries or fatalities. The review team noted that the previous fire
and had been experiencing low to moderate fire behavior during 2 previous days and up until
behavior lulled the burn team into complacency. They were also operating "blind" by not
1400 hrs when incident occurred (wind shifted and RH's dropped quickly). However, burn
using lookouts nor taking weather to maintain situational awareness. Need for good and
boss did not outline his expectations for lighting crew well so they were unsure of what they
thorough briefings pointed out especially when dealing with lesser experienced personnel.
were doing. The lighting crew was not directly supervised at the time by an Ignition
Complexity was underrated relative to national policy (review also noted that with 3 ignition
Specialist. The assigned Ignition Specialists were in another area of the burn using a terrateams should have been rated a moderate complexity). Unanswered question - if this were a
torch. Visibility of the lighting crew was hampered by terrain and the burn boss could not see
wildfire would these people would have behaved the same way as on this prescribed burn??
this area directly either. No lookouts were used during this operation and weather was being
taken sporadically throughout day.
Day of ignition contained slopover during blacklining operations. 2nd day blacklining
continues, but not burning well so burn boss changes from backing fire to strip head fire.
Fire activity picks up greatly with flame lengths reaching 7-10 feet. Slopover onto pvt
ground, but contained. Patrolled every other day including the morning of the escape. At
Cordgrass (escape
1600 hrs the manager receives report of a lot of smoke coming from unit. Resources
named Pin Oak)
respond and extinguish, but burn 3 more acres of pvt. ground. Day of escape changing
winds and trend of dry weather allows fire to become active. Part of the chain of events
leading to escape were - exhaustion from previous burns & wildfires, underestimating low
fuel moistures & inadequate patrolling.
Navajo Ridge
Appendix B
Information not from a review document. Information is from a prepared slide presentation
about the escape. Again, without documentation we be losing lessons learned and
knowledge beyond audiences that have seen this. Mentioned in presentation that this
incident (due to mopup procedures & methods) was the 2nd occurrence in this area in 3
years. This burn also relied on "nighttime recovery" to contain burn, but environmental
conditions were not adequate in this case to control burn. No monitoring was occurring to
verify nighttime forecasts.
Documentation not clear on start/stop of ignition and spots. Not sure how many times
ignition was stopped then started due to spotting. Good response from contingency forces
noted. Test burn indicated "no holding problems". The report indicates but does not
Finding in this report did not have sufficient detail to add to this section.
elaborate that on-site observations indicated there was for the potential for escape identified
prior to ignition.
This draft review seemed mostly to focus on policy and procedural review as well as the
need for coordination with cooperators and public. The report did note that the burn was
implemented on a day with weather predictions on the "dry and warm" end of the
North Shore Kenai
prescription. Warm temps and low RH's were predicted and continued to exist until the fire
Lake (Draft)
was declared an escape. Decision to burn was based on success of burn in same area 2
years prior although conditions were not the same in both years. The report did not
elaborate on enough details.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
4
Regional policy outdated relative to national direction. Insufficient dedicated resources were
available to conduct burns. Having good interagency/cooperative partnerships were noted as
being key to successful fuels program. The importance of relationships with the public
(appropriate coordination, involvement and awareness of prescribed fire activities and fuels
treatment planning) is a reoccurring recommendation from other escape reviews.
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Anatomy of the Escape - What were the "weak signals"
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Burn Plan was for a different area originally done in 1999 and may have been part of a
ongoing landscape burn effort starting in '92. Spot forecast predicted favorable conditions
for burn ops, but T-storm were also forecasted high with winds reaching 30-40 mph "near"
Pot Creek (DRAFT)
cells. Burners thought they would not experience these winds since they were 20-30 miles
away from cell. T-cells were not visible yet when ignition started on the unit. Had tough time
burning or getting sage to go during ignition. Had more holding resources than BP required.
Rock
Wilson
Appendix B
Review has detailed chronology/narrative. Could be used as case study. Nov. 11, '99. An
attempt to burn unit. During test fire, spotting into brush occurred above a road. Two other
attempts were postponed. 4th attempt - 1st day of burning (50 Ac) completed what was
considered the "toughest" part due to frost-killed brush above road. 1st day Test fire started
~0636 hrs. Ig began ~0738 hrs. 1300 hrs RH (12%) drops out of prescription. 5th attempt escape. Burn boss(es) kept on attempting to compensate for conditions (contingency
resources, starting ig early, etc). While burn personnel took many steps at what point should
the "signals" triggered a "no go" action? If you have to work that hard to pull a burn off and
you are at the upper end of prescription then maybe need to re-evaluate.
No single document of this escape. Some information in documents vary from each other.
The review document was only a draft and unknown if every finalized. The role and issue
concerning the potential of burning when thunderstorms or cells are forecasted near burning
not fleshed out and resolved. One area noted in the review needing improvement was
communication and coordination of the cooperating agencies involved in this project.
Review noted some confusion with interpretation and use burn personnel had with new burn
plan template. This was noted by review team in trying to determine if burn was conducted
"within prescription". Burn personnel did lots of weather analysis especially looking at wind
speed and direction & RH. Much attention was focused on the diurnal wind speed and
direction. However, the RAWS station trends for winds did not show the larger scale,
"notorious" pattern that was cited as the main cause for the escape. The "notorious" pattern
was one known for rapid drops in RH resulting in low RH's and higher winds speeds. This
burn was conducted on the "hot" end of the prescription so the time of day RH would drop out
of prescription was carefully considered. Weather analysis showed that RH would drop out
of prescription between 1200-1300 hrs each day.
Noted in report "with the shift in the fuels program toward more urban interface prescribed
All personnel assigned to Rx fire were qualified and experienced. Holding and mopup plans
burns, more thorough documentation for all phases of project implementation may become
were "weak" in that they did not contain triggers for actions or contingency.
useful."
These burns were part of two ongoing projects which had prior successes burning other
Anderson/ Danskin
blocks with no escapes. Active monitoring of both burns and weather was occurring. A
(this review covers
Main recommendation for improvement was for increasing communication with the weather
"high wind" event caused both burns to escape. A local weather station recorded sustained
service (NWS).
2 separate burn
winds of 30-35 mph which helped move fire from surface to crown fire which burned over
project areas)
snow.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
5
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Anatomy of the Escape - What were the "weak signals"
Appendix B
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Programmatic burn plans - this review indicated that these could be ok IF burn personnel had
enough detail regarding the area being ignited. Three main areas which needed detail are 1)
The burn plan did not include all mitigations from NEPA document including sensitive fish
what constitutes an escape 2) specific mop-up & patrol standards and 3) detailed maps
species and smoke monitoring. Both burn plans lacked sufficient detail (deficiencies) in
which display planned ignition areas, locations of holding forces & critical holding points,
Sanford (this review contingency, holding, mop-up & patrol. This review mentions the potential problems that can
location of sensitive areas and/or resource values & human safety considerations. The
covers 2 separate arise with long-duration, landscape scale Rx burns. This is one of several reviews that
review also noted that training in preparing "good" burn plans was lacking (Note: Rx300 Burn
burn project areas) mention when burners are relying on vegetation (fuel) or fuel moisture changes need to have
Boss is only course at this time. NWCG is in the process of creating a course which focuses
other indicators (e.g. measurable drought indicator such as ERC, etc) to signal when they will
on burn plan preparation). Public involvement and awareness was mentioned as another key
no longer work. (Note: this was a reoccurring theme in numerous reviews)
area that was lacking and becomes important when things do not go well or as planned.
(Note: Puma review also touched on problems with using programmatic burn plans).
Blanco
Cascade II
Cherry
Area previously burned ('93) with less than desired results (did not burn crowns of p/j). Test
fire & primary ig occurred in mixed p/j community below rim of mesa top. Blacklining had
been completed in April. Test fire & ignition rapidly built into a crown fire and spotted across
blackline (est. spotting distance .5 - .75 mi) All burn personnel committed to spot. Unable to
contain. Again, another problem is appropriate selection of fuel models and addressing
mixed vegetation-fuel complexes within the burn area. In this case they used only one fuel
model, but was not reflect the primary carrier of fire which under predicted potential fire
behavior caused an underestimation of holding force needs. The fire behavior in P/J again
was the veg-fuel complex that caused "surprise". Long-term drought and effects to fuels/fire
behavior was also mentioned as a contributing factor not adequately considered.
Burn plan "technically" adequate. However, review team note a need for "further refinement
and additional information for clarity" to improve the plan. This review like others addressing
escapes with landscape-scale burns noted the challenge in burn plan preparations to seek
the balance between sufficient detail to changing situations over time while allowing sufficient
flexibility for the burn boss and line officer to manage the project. Burn area design was
noted as a problem - did not develop a unit boundary based on fire behavior characteristic.
The review noted a contribute factor to problem of unit design was area was originally
designed to have mechanical treatment so needed archeological clearance, but clearance
was not completed so area was excluded from burning at this time. Burn plan also did not
include all mitigations from the NEPA document.
Test burn was not conducted in a representative location. Test was done in a cooler, more
protected area than area to be ignited. Low rates of spread were observed with test burn.
Numerous findings in report. Key was burn plan weaknesses. Repeat finding that the burn
plan did not have enough detail for a high complexity burn. Along with other publicly visible
escapes - Cerro Grande, Lowden, Sanford (and those that surprise I.e. impact the public) the
importance of public involvement and awareness before, during and after prescribed fire
implementation was noted in the review.
The burn was set for implementation a week prior to actual execution. The burn was
delayed to get "hotter" prescription needed in this fuel type. Anticipating this areas were pretreated (2,500 acres) which did increase the ability to protect the community during the
escape. Burn plan ok, but improvements were noted in the areas of risk assessment
including threat identification and mitigations. Complex burn plan execution requires
increased "situational awareness", appropriate resources and monitoring. It was unclear to
review team that fire behavior was monitored and what if any role it played in decision
making.
Review provides numerous good recommendations on how improved burn plans and
specific areas that need attention when addressing complex, landscape scale burns. One
area noted was developing regional guidance to have an objective method for assessing
risks including potential for escape, evaluation of threats to the boundary, communities,
developments and sensitive resources; identification of critical holding points; & mitigation
actions to mitigate or eliminate threats. This is different than the NWCG complexity rating.
Recommendations for use of "management action points".
Prepared by D.Dether
Forest Fuels Planner, Boise NF
6
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Anatomy of the Escape - What were the "weak signals"
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Aspen stands & roads expected to contain fire. Did test fire, and results determined to be
acceptable. Ignition proceeded, but conducted at the upper end of prescription parameters.
No one monitored the fire overnight. The morning following ignition found that the fire had
Petty Mountain Near
burned through the aspen stands during the night. The original plan was developed for a
Miss
spring burn which should have stopped fire spread as planned, but burn was implemented in
fall instead so aspen area drier than originally desired and anticipated to act as a natural
barrier.
Puma
Sink's Canyon
Appendix B
The review dealt with numerous policy and procedural issues. The review team looked at a
number of areas, but boiled it down to 4 areas - policy, prescribed fire plan, safety and fire
program leadership. The review determine the plan was not a "good" plan and they did not
follow the plan even the "good" parts of the plan - and amendments were not reviewed and
signed. Review determined that ignitions occurred in units that were outside the burn
prescription and approved burn areas. Used only the general fire weather zone forecast, did
not use spot wx forecasts or local RAWS data to determine if in prescription or more site
specific forecasted weather info. Snow was suppose to be used as a containment for this
type of burn/burn plan, but not enough snow to contain.
The AAR suggested that rather than "amend" a spring burn plan it was better to write a new
plan to deal with current conditions. The amended plan was confusing because of the mix of
information. Issues arose over project design and adequate NEPA to cover both a spring
and fall burning scenario. The allowable burn area did not cover the logical burn area for fall
burn. Also recommended improvements to establish clearly stated and measurable
objectives in the NEPA document that could be carried right into the burn plan. If the
objectives are not measurable and cannot be monitored then they need to be written into a
burn plan so they are.
Regional policy outdated and not consistent with national policy (this had come up in other
reviews). Burn plan did not contain all elements required to be in a burn plan. Had been
using a "master" burn plan and did not contain sufficient site-specificity. Many key elements
of the burn plan listed as missing the site-specificity including maps of approved burn areas,
holding, patrol, mop-up and contingency. This report brought up an issue not evaluated in
other regarding qualifications of the line officer and delegations of authority. This report
indicated that delegations to District Rangers need to be based on the "qualifications and
experiences" not to the position. Also, although the burn boss was qualified as RxB 3
concerns were raised about the complexity of burn (i.e. higher than "low") and should have
been implemented with a RxB2. Review stressed need for burn personnel to maintain
"situational awareness" even for prescribed burns.
This was another review in which the issue of "no substantial definition of an escape" was
rased as a problem. The review recommended that there needs to be a solid definition so
there is no question of what (and when) there is an escape. Allowable burn area and sign of
Fireline was 5' brush line w/ 18" handline. Winds shifted and RH dropped to 15% which
boundaries again raised as an area that needed to be addressed. Need to design burns with
moved fire to burn into decadent bitterbrush in a "bowl" and jumps line. Fire continues
more logical burn boundaries. Review also recommended to better evaluate fuel "inclusions"
following heavier fuels (bitterbrush & Juniper) cross-slope above rock cliffs & snow banks.
as sources of trouble. If the un-modeled fuel pockets had been evalauted with burn day
Fire spread checked at rock outcrop. 2000 hrs winds die down and so does fire. 3 days later
conditions it would have indicated it was outside of prescription parameters. A spot weather
after mopup and girding smoke reported @1500 hrs. 1730 hrs spot fire was actively spotting
forecast was requested/received, but forecast did not accurately predict actual conditions
& torching. Spotting 200' from rock outcrop that stopped fire spread before. Burns 4 more
(wind shift later in day). Review team interviewed another burn boss in same area & was told
acres.
of similar "problems" with forecast accuracy. Recommendation from review was for burn
personnel to gather more local weather data, provide feedback & work with NWS office to
increase accuracy.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
7
6/29/2005
Prescribed Fire Escape Reviews
Project Name
Anatomy of the Escape - What were the "weak signals"
Appendix B
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Numerous items were of concern in this review. Burn boss made numerous changes to
complexity and burn operations not in plan and without getting line officer approval. Due to
changes made, the burn plan was deficient (e.g. added aerial ignition, but did not aerial org
chart to plan) relative to the burns as implemented. Also, change in complexity to high also
raised questions about RxB qualifications. Burn boss was RxB1(T) and was only coached
Impassable Bay
1st day. Review noted failures of the RxB coach to ensure things were done properly. One
(Compartments 16
direct causal factor noted was prior years of drought & low spring ppt levels made swamp
& 117)
levels lower than "normal". The "swamp" was suppose to provide natural barriers, but due to
drought it was dry and did not check fire spread. There was no documentation of this being
checked although in one of the burn plans it specifically stated "ensure adequate water level
in swamp to contain fire." Only, one FM was used to fire behavior, nothing for swamp &
transition zones which would have much higher rates of spread.
These burn blocks were originally prepared and planned to be implemented separately, but
implemented simultaneously which then created numerous other inconsistencies relative to
policy and procedures. Another interesting note was the confusing direction between
national, regional and Forest level manual and LMP/FMP. The issue of lack of consistent
direction/policy below the national level came up in three of the other reviews. As in some
other reviews this burn was not declared an escape when it should have been. There seems
to be a gap in putting clear "triggers" for when an escape should be declared. Management
of burn personnel - work/rest ratio exceeded & personnel arriving on burns without being part
of assigned resources (this was a "normal" operation) caused safety issues. Management
and leadership for the burns "changed hands" many times from the initial RxB (T) with trainer
to others not currently qualified. Transitions were not well conducted.
Island Lake
Overall the review noted that this burn was well planned and prep. Speed of ignition (ring- The AAR noted that it was important for the burn boss to get "the big picture", but in this case
it was hampered by terrain and access. Recommendations to compensate for this was to put
fire of interior) probably contributed to escape - too much fire, too fast. Winds (increase in
speed and direction) in river canyon noted at a "localized" event. Spotting distances with high observation points on burn maps and utilize lookouts. Also, noted strategies to deal with
RH's over a water body unexpected. Another "surprise" to burn personnel was the floating, tricky, transition times of the day when igniting were river canyons can be difficult. This
flaming mats of vegetation although not the like source of ignition causing the escape. The keeps on being a repeat "lessons" -- know you local weather. Also, noted in this review as a
potential for spot fires was included in the burn plan with mitigation measure; however, with reoccurring recommendation to have MOU or agreements with land adjacent landowners.
low water conditions made river-based holding forces ineffective. Thick smoke also was
The review also noted that slower ignition is warranted in these fuels and in this topography
noted as something that hampered the use of the helicopter for bucket work. The lack of
(river canyon). One lesson learned recommendation about contingency was a thorough
communication with all burn personnel due to radio dead spots and background noise from recon is invaluable. Think about the worst case scenario and then imagine the worst case
equipment was also an issue noted.
scenario going bad, then go back & plan your contingency.
Long Jim III
Burn plan ok & had thorough technical review. Burn personnel all qualified. Weather was
suppose to be monitored 7 days prior to burn plan, but only taken day prior to burn. ERC
were "above average", but below 90th percentile. 1000-hr TLF were "below normal", but
within prescription. More active fire behavior than anticipated was observed during blackling Critical timelines that are established to ensure success of operations need to be tracked and
ops and test ignition and cited as the reason why ignition of the unit needed to be completed reassessed frequently so that adjustments or mitigations (I.e. ignition pattern or method) can
by 0900 hrs. A serious of mechanical and logistical problems & delays caused the ignition to be made early enough in the operation period to secure successful completion.
go 2 hrs beyond planned completion timeframe. The RxB1/ICT3 indicated not having seen
this kind of crown fire behavior & consumption in P/J in nearly 2 decades at this particular
unit.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
8
6/29/2005
Prescribed Fire Escape Reviews
Appendix B
Project Name
Anatomy of the Escape - What were the "weak signals"
Key Lessons Learned / Emerging Best Practices / Knowledge Gaps
Meadow
All burn personnel were qualified for their positions. Once again, the review cited an "above
normal" loading of cheat grass was not anticipated to be a major influence on the increased
fire behavior by the burn organization. Even with policy in place as part of the "Go/No Go"
which specifically address this situation did not provide an "mental check". First phase of
this project conducted in the spring with poor results and conditions that did not burn well. In
the fall, fine fuel conditions changed from that of the prior spring by adding a "short, but
dense" layer of cheat grass. This review noted similarities with another burn on a different
unit that has similar experiences with short, dense cheat grass and creating spotting/holding
difficulties. Other "procedural" and/or "operational practices" were noted in this review.
Review again stressed the need to gather on-site data relative to prescription parameters
prior to burning. Incorrect use of fire behavior modelling may have misled burn personnel to
underestimate potential flame lengths and probability of ignition. The potential for
thunderstorm development was forecasted (LAL 4) and burn personnel reported seeing Tstorm to south but proceeded with burn. Signing Agency Administrator had not attended
"mandatory" training for Fire Program Leadership was noted by the review team. This is first
time issue of administrator's qualifications raised.
Several good lessons for landscape prescribed fires. When designing burn block boundaries
consider factors such as terrain influences on fire behavior, natural barriers, and fuel
1st attempt at landscape scale RxB. Evaluated complexity only for each burn individually.
changes. Drainage and mid-slope lines in continuous fuels should be avoided if possible.
One helicopter for both, but had to stop lighting on one to do bucket work on other. Other
During multiple ignitions with long travel times separating them support for each block must
Mitchell & Hot Air factors that contributed to the escape - lower than expected RH recovery, insufficient depth include separate holding forces to deal with the potential for multiple escapes. Also, related
(this review covers of blackline with unburned islands of fuels, concurrent operations on two units 15 miles apart to igniting multi-blocks when aerial ignition is used and the same helicopter is also key to
holding/contingency on both units then should consider either having another helicopter as
2 separate burn & burn block boundaries located at mid-slope & canyon bottoms with continuous fuels.
Complex ignition patterns to meet resource objectives & multiple fuel models created large contingency or ignite only one block at a time. With complex, mutli-block burns may need to
project areas)
unburned areas w/in boundary were allowed to burn "freely". As weather became warmer & consider both day & nighttime staffing. Considerations for containment of burns is a
drier fire behavior created spotting problems that challenged holding resources daily.
reoccurring issue in reviews. In this case, blacklines were not sufficient in depth & extent to
hold this complex fire. The review cautions burn bosses to take time to assess & evaluate
conditions to assure proper reductions in fuels has or is occurring before ignitions.
Prepared by D.Dether
Forest Fuels Planner, Boise NF
9
6/29/2005